REGULATORY COMPLIANCE AND RESIDENT OUTCOMES IN OREGON ASSISTED LIVING COMMUNITIES

Abstract The outsized negative impact of the COVID-19 pandemic among residents of assisted living (AL) communities has drawn attention to the existing challenges that licensing agencies face in providing oversight in this setting. While regulatory compliance inspections in AL may be a critical tool for promoting high-quality care, no published research has examined the association between deficiencies and resident outcomes in AL. Using novel data collected from 331 AL communities in Oregon (response rate=62%) merged with deficiency data from inspections, we examined whether the number of deficiencies is associated with the following resident outcomes as measured at the community level: share of residents who fell at least one time (fall rate), who were hospitalized overnight (hospitalization rate), and who were treated in the hospital emergency room (ER rate) in the last 90 days. Negative binomial regression models that controlled for a robust set of community (e.g., size, rurality, profit status, “memory care” units) and resident (e.g., age, Medicaid use, ADL needs) characteristics showed a weak, but statistically significant, association between deficiencies and hospitalization rate (IRR=1.05). However, there was no statistically significant association between deficiencies and falls or ER visits among residents. The time lag between inspections and the resident outcome data did not moderate these observed associations. With more states moving to make available such deficiency data on public-facing websites, these results have policy implications for the role and content of regulatory compliance inspections for ensuring quality in AL communities and informing the public.

The Centers for Medicare & Medicaid Services (CMS) is the largest payer of nursing home care in the US. CMS defines staffing levels as hours per resident day (HPRD) and staff turnover rates; it defines quality of care as nurse staffing levels, hospitalization rates, resident outcomes, and deficiencies (violations of regulations). However, these definitions have been inconsistently applied in the research literature, which has led to equivocal results in research on the association between staffing levels and the quality of care in nursing homes. We conducted a scoping review of how nursing home staffing levels and quality of care have been defined and measured in the research literature, guided by the PRISMA (Preferred Reporting Items for Systematically reviews and Meta-Analyses) framework. Out of the N=423 initially identified studies through PubMed, N=67 articles were selected, based upon the following inclusion criteria: 1) published after January 1, 2010; 2) published in the US; 3) focused on determinants of nursing home staffing levels or determinants of quality of care. Two independent reviewers conducted abstract screening and data extraction. The findings from our review showed that approximately 50% of studies partially adopted the definitions from CMS. For example, HPRD and deficiencies were utilized to measure staffing levels and quality of care in N=37 and N=12 studies, but none of them included all suggested measures. Future studies should carefully consider the approriate definitions as specific measures can yield contradictory associations between staffing level and quality of care, easily leading to confusion for policymakers. The outsized negative impact of the COVID-19 pandemic among residents of assisted living (AL) communities has drawn attention to the existing challenges that licensing agencies face in providing oversight in this setting. While regulatory compliance inspections in AL may be a critical tool for promoting high-quality care, no published research has examined the association between deficiencies and resident outcomes in AL. Using novel data collected from 331 AL communities in Oregon (response rate=62%) merged with deficiency data from inspections, we examined whether the number of deficiencies is associated with the following resident outcomes as measured at the community level: share of residents who fell at least one time (fall rate), who were hospitalized overnight (hospitalization rate), and who were treated in the hospital emergency room (ER rate) in the last 90 days. Negative binomial regression models that controlled for a robust set of community (e.g., size, rurality, profit status, "memory care" units) and resident (e.g., age, Medicaid use, ADL needs) characteristics showed a weak, but statistically significant, association between deficiencies and hospitalization rate (IRR=1.05). However, there was no statistically significant association between deficiencies and falls or ER visits among residents. The time lag between inspections and the resident outcome data did not moderate these observed associations. With more states moving to make available such deficiency data on public-facing websites, these results have policy implications for the role and content of regulatory compliance inspections for ensuring quality in AL communities and informing the public.

NOWHERE ELSE TO GO: EFFECTIVENESS OF THE PASRR PROGRAM TO MEET THE NEEDS OF RESIDENTS WITH SMI ADMITTED TO NURSING HOMES
Taylor Bucy 1 , Tetyana Shippee 2 , Mark Woodhouse 2 , John Bowblis 3 , Shekinah Fashaw-Walters 1 , and Nathan Shippee 1 , 1. University of Minnesota School of Public Health,Minneapolis,Minnesota,United States,2. University of Minnesota,Minneapolis,Minnesota,United States,3. Miami University,Oxford,Ohio,United States The number of adults with serious mental illness (SMI) who receive care in nursing homes (NHs) continues to rise. The Preadmission Screening and Resident Review (PASRR) program requires screening for SMI prior to NH placement, in order to avoid inappropriate admission and unnecessary institutional care. We interviewed staff responsible for the processing of PASRR documentation at four NHs in Minnesota (n=15), and obtained and analyzed all completed PASRR-II assessments in Minnesota from 2019 (N=532). PASRR assessments overwhelmingly recommended 24-hour NH care (94.7%) with 94% of assessments indicating a need for mental health services while at the NH. Most NH staff interviewed noted that PASRR is not used in the care planning process and described PASRR as a regulatory hoop. Staff shared that PASRR assessments could provide insight into an individual's mental health history, current and future needs, and can be helpful in assessing NH capacity to provide such services. Although mental health services provided while at the NH are supposed to be facilitated in partnership with the county, there is a lack of follow-up and NH staff are largely left to deal with SMI in isolation. PASRR assessments are supposed to be a tool for care coordination, but leave the NH as the sole responsible point of contact for residents with SMI. A more integrated PASRR program that better focuses on incorporating PASRR into care planning and mental health service delivery in NHs and the broader community is necessary to improve the lives of individuals with SMI.

SERIOUS MENTAL ILLNESS IN MINNESOTA NURSING HOMES: THE ROLE OF RESIDENT AND FACILITY CHARACTERISTICS
Tetyana Shippee 1 , Taylor Bucy 2 , Weiwen Ng 2 , Mark Woodhouse 1 , Shekinah Fashaw-Walters 2 , and John Bowblis 3 , 1. University of Minnesota,Minneapolis,Minnesota,United States,2. University of Minnesota School of Public Health,Minneapolis,Minnesota,United States,3. Miami University,Oxford,Ohio,United States Multiple studies have shown an increasing prevalence of adults with serious mental illness (SMI) in nursing homes. As adults with SMI age, the reality of care needs that span physical, medical, and psychosocial services necessitates further consideration of the role of comprehensive, ancillary mental health services in nursing homes (NH). Yet, little work examines characteristics of those with SMI, their care needs & the role of facility structural factors. Using the 2011-2017 Minimum Dataset (MDS) assessment data for Minnesota, we examined resident-level demographic characteristics of NH residents with and without SMI, and facility-level characteristics including quality of life (QoL), quality of care (QoC), and state recertification survey scores. We defined SMI as a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, or psychotic conditions other than schizophrenia present on the reference assessment. Individuals admitted with SMI were younger, had better physical health, were more likely to be racial/ethnic minorities, and more likely to be admitted to a facility with a higher proportion of racial/ ethnic minority residents. SMI-only admissions were concentrated in larger, for-profit facilities with a high-reliance on Medicaid. Lastly, SMI-only admissions were more likely to occur in facilities with lower QoL, QoC, and inspection scores. There is a growing need for behavioral health services in NHs, yet access to services is inadequate and lacks equity based on geography, race/ethnicity and other system-level disparities.

NURSING HOME PALLIATIVE CARE DURING THE PANDEMIC: DIRECTIONS FOR THE FUTURE
Kacy Ninteau 1 , and Christine Bishop 2 , 1. Dana Farber Cancer Institute,Boston,Massachusetts,United States,2. Brandeis University,Waltham,Massachusetts,United States For this qualitative, pilot study, seven Massachusetts nursing home Directors of Nursing (DONs) were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated the solutions nursing home staff developed to provide palliative care during the COVID-19 pandemic despite restrictions on external resources. Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization status and options for care given COVID-19 resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic.

ROLE OF ACTIVITY PROFESSIONALS IN APPLYING APIE MODEL TO ENHANCE RESIDENTS' ACTIVITY IN LONG-TERM CARE SETTINGS
xiaoli li, University of North Texas, Frisco, Texas, United States Innovation in Aging, 2022, Vol. 6, No. S1